Screening for Brain Injury

Rodney Isom, Ph.D.

TBI

• TBI-Traumatic Brain Injury– When the head is hit (closed head injury)– When the head is shaken violently (closed head

injury)– When the head is penetrated (open head injury)– Loss of oxygen to the brain (closed head injury)

TBI

• The CDC estimates 1.4 million new cases each year.

• Of that it is estimated that 80,000 to 90,000 have long lasting symptoms

• 50,000 die each year• There are 5.3 million Americans with Brain

injuries that need help with ADL’s.• The CDC has no estimate for number not

diagnosed, however, it is a big number!

TBI and Work

• 28.2 % employment rate for people with cognitive disability

• 14 % working full time/full year.• $30,600.00 Median earnings for non-

institutionalized Americans 18-64 working full-time, full-year.– American Community survey 2008

The Brain

• Soft mass of tissue floating in cerebral spinal fluid.

• The skull - hard bony interior surface with protruding ridges (not sure why God put them there).

• Frontal lobe, temporal lobe, occipital lobe, just a few of the parts of the brain, but dang important ones.

Brain deficits

• Physical• Cognitive• Executive• Psychological

Brain Deficits

• Physical- sensory-motor deficits, motor deficits, fatigue, seizure disorder, decreased tolerance to alcohol and drugs, headaches

• Cognitive– Disorders of learning and memory– Disorders of complex information processing– Disorders of perception and communication

Brain Deficits

• Executive Function– Planning, initiating action and carrying out plans• Not related to severity of injury• May appear

– Unmotivated– Disorganized– Never completing tasks– May lose friends and jobs– May be able to perform every aspect of the job, but cannot

hold the job due to their inability to plan, initiate and carry out action.

Brain Deficits

• Psychological-may exhibit– Impulsive behavior– Disinhibited behavior– Lack Initiative (adynamia)– Personality change– Changing relationships due to personality change,

may lose family and friends

Frontal & temporal lobe

• Fronto-temporal lobe contusions– Problems with learning and memory– Problems with planning, organizing, and problem

solving– Problems with emotional control

• Most important for understanding brain injury• Again not related to severity of injury.

Frontal & temporal lobe

• Frontal lobe controls– Planning– Organization– Problem solving• Abstract thinking• Developing problem-solving strategies• Integrating diverse information• Diminished control over emotions

– Childish behavior, rage, easily angered or frustrated, impulsivity and disinhibition

Fronto-Temporal Lobe

• Temporal lobe controls– Memory structures for learning new information– May be unable to recall recently learned

informationbefore or after TBI.

Type of injuries

• Coup-contrecoup– Struck with enough force to damage the part of the

brain directly behind the blow and then causes the brain to bounce of off the opposite wall of the brain, causing injury to the part of the brain that rebounded

– Diffuse axonal injuries• Stretching or tearing of nerve fibers throughout the brain

causing diffuse or widespread injury• Maintaining arousal, attention, and vigilance, motor

disturbance, slowed mental speed, diminished control of the emotions.

Assessment of Brain INjury

• Glascow Comma Scale- 3-15, 15 is good, 3 is real bad, done at time of injury, an acute measure. Believed by many to predict severity of disability after recovery.

• MRI- functional magnetic resonance imaging • PET- Positron Emission Tomography • SPECT- single photon emission computed tomography• EEG- electroencephalography• QEEG-quantitative electroencephalography • Brain Dedicated SPECT Scan—very promising!• Neuropsychological Testing—usually the definitive answer.

Neuropsychological Assessment

• Neuropsychological assessment is a method for evaluating multiple areas of functioning including attention, mental flexibility, memory, auditory and visual processing, language, concept formation, executive functioning and problem solving, as well as planning, intelligence, academic skills, behavior, emotions, personality and more recently, effort. The assessment is designed to detect aspects of performance that will clarify the nature of possible strengths and weaknesses within specific domains, as well as identify neuroanatomical correlates in the brain.

All Other forms of Assessment

• Most of the other assessment tools may or may not show brain damage.

• The amount of brain damage does not necessarily correspond to the loss of function.

• You can have a “minor brain injury” but be unable to work, or conversely a “severe brain injury” and have a stellar career.

The Problem

• Our Clients often are injured and have other life threatening injuries, more obvious, more urgent.

• PT’s discharged and told if you still have a headache in a month, come back and see me.

• Family doctors often miss the diagnosis• Nearly all symptoms of brain injury can be

attributed to other causes.• Anosagnosia- People with brain injury often don’t

recognize problems associated with BI.

TBI

• What we know– Brain injury once it occurs is permanent.– Symptoms of brain injury may improve over time,

but most of the recovery occurs within the 1st 12 months (90+%).

– Most symptoms will first be noticed after the accident (the smoking gun!) Some may have existed prior to the accident and become worse.

– No one is better off after a brain injury.

Symptoms of TBI• Persistent headaches and neck pain• Difficulty remembering, making decisions or concentrating• Difficulty or slowness in speaking (slurred speech), thinking, understanding or reading• Becoming lost or confused easily• Loss of energy or increased sleepiness• Quick mood changes, such as becoming suddenly sad or angry• Sleep disturbances, either insomnia or chronic fatigue• Lightheadedness, dizziness or inability to keep balance• Nausea or sudden urge to vomit• Loss of fine motor functions• Amnesia• Increased sensitivity to sounds, lights or distractions• Blurred vision or easily tired eyes• Loss of sense of smell or taste• Ringing in ears

Symptoms of TBI

• Extreme irritability, anxiety or rage• Personality changes• Depression, sometimes as a result of lost

abilities from the initial trauma• Extended cognitive problems or inability to

solve everyday problems• Emotional or behavioral disorders, including

difficulties in relationships, work or school• Seizures

Screening for Brain Injury

• We screen to determine if we need additional diagnostics.

• 1st sign of potential brain injury, MVA (belted or not), bump on head, broken wind shield, loss of memory of the accident, confused state after the accident (does not have to have loss of consciousness), loss of memory just prior to accident.

Screening for Brain Injury

• Other types of accidents,– Falls from 10 feet or higher, where head is hit.– Hit in the head with force (can be with helmet)– Any accident that causes a large bump or bruise or

cut on head or face.– Any event that might cause a lack of oxygen to the

brain, drowning, caught in a fire, strangulation.– Mostly it is physics, force will pass through skull,

and into brain if sufficiently strong enough.

Screening for Brain Injury

• So once a action takes place that might cause brain injury screen for it.– Ask about their memory, how is it?– How about their balance? Get them to

demonstrate, standing on foot at a time (be sure to stand close in case that start to fall), then repeat with their eyes closed).

– Have them grip your fingers as hard as they can, is there a difference? If right handed is their left stronger?

Screening for Brain Injury

• Ask them if the get lost, when they shouldn’t?• Having trouble sleeping?• Do they get real fatigued in the afternoon?• Ask the client or claimant if anyone close to

them have noticed or commented “that they not the same person” or “that they seem to have changed.”

• If you can speak to a spouse or relative ask them if the client has seemed to change?

Screening for Brain Injury

• Ask them if there are things they can longer seem to do or for some reason just don’t enjoy anymore? And why?– Reading?– Working puzzles?– Just working things out in everyday life?– Can they get things done now?

Screening for Brain Injury

• Have they had any recent trips to ER?• Has their drinking or drug use gone up?• Have they been in any fights or near fights? Is

this unusual for them?• Have they been arrested since the accident?

What for?• How are they getting along with others that

are close to them?

Screening for Brain Injury

• Do they remember to take their medication? Does someone at home help them with this?

• Have they burned anything on stove lately? Is this common? Did it happen before the accident?

• Walk off and leave the front door open?• Made any strange or impulsive purchases in

the recent past?

Screening for Brain Injury

• How do things smell now? • Does food taste the same?• Do their ears ring now?• How is their appetite? • Are they depressed?• Do they have nightmares?• Have they had a seizure?

Screening for Brain Injury

• If some or most or even a few of these symptoms are endorsed,

• And they got hit by a car, truck, train, bus, or they fell of off a cherry picker, a tall ladder, the 3rd floor balcony, or were burned over a good portion of their body and it included their face, or were stabbed or shot in the head,

• And all or most of the symptoms started after the accident--- Refer to a Neuropsychologist!

Referral

• Just because someone is a psychologist, doesn’t mean they can or will diagnose someone with a brain injury.

• Just because someone is a counselor or social worker, doesn’t mean the can or will diagnose someone with a brain injury.

• A board certified neuropsychologist will give you the best evaluation, they will not only tell what part of the brain is injured, but what the functional impact of the injury is.

Referral

• If you do a neuropsychological, before the one year anniversary, plan on doing another at the one year anniversary.

• Don’t hold off doing until the one year anniversary, the more immediately BI is identified, the sooner we can help people to cope with their brain injury.

• If you do any kind of scan, and find that they have a brain injury, you still don’t know how the injury has manifested itself, you still need a neuropsychological.

Referral

• Lastly, but not least, if you are going to try and get someone with a brain injury back to work, use a certified rehabilitation counselor, with experience in working with people with a brain injury.

• People with brain injury, need more time to learn, more time to practice what they learned, you cannot assume that they can transfer knowledge or skills, to another area or system, they are vulnerable to change and need as mush constancy and consistency in the work place as possible to have a chance at vocational success.